Provider Demographics
NPI:1033267216
Name:ADVANCED FAMILY CARE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ADVANCED FAMILY CARE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-588-0084
Mailing Address - Street 1:1201 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2432
Mailing Address - Country:US
Mailing Address - Phone:323-588-0084
Mailing Address - Fax:
Practice Address - Street 1:1201 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-2432
Practice Address - Country:US
Practice Address - Phone:323-588-0084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33986261QM1300X
CANMW1068261QM1300X
CAA88137261QP2300X
CAPA16806261QP2300X
CAG42217261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0077511Medicaid
CAGR0077511Medicaid